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HomeMy WebLinkAbout26-474 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG69584OLCERA COLLISION REPORT 1591971 ❑ 0 RESULTED I $ 26-474 2 INTERSTATE CITY STREET FIRESTOLENSTATE ROUTE OTHER VEHICLE LDCALANG 4200 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 TOTAL#OF OBJECT 1 1 s 28 TRIBAL UNITS 02 STRUCK RESERVATION : 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# DATE OF N E eDL�ISION' 01 - 16 - 2026 1530 17 =.�� S W OF 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑ SUNSET BLVD N BLOCK NO. e 300 .� 4a❑ MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 MILES 1.1 FEET e S 8 W e N 3RD S 0 1 29 MOTOR PEDAL- DAM AG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YES ✓NO 0 8 30 6 LAST NAME RUSSELL FIRST NAME KAPSAAN MIDDLE t 1 2 31 INITIAL STREET ] 9743 WATERS AVE S, CITY; SEATTLE ST WA ZIP; 98118 2 NEW ADDRESS 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCKYEs Na✓ INTERLOCKVEs NO✓ YES F N( DRIVER' # STATE WA SEX M MM0,13. 05 — 19 — 1999 t 1 2 32 8❑ 9 ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT 1 H USEET CLASSY 1 NATURE of INJURIES 2 LICENSE, CGN4666 STATE WA VIN# 3N1AB7APOKY309790 3 10 Fl I PI ATP rt TRAILER STATE TRAILER STATE ROM To 11 3 0 PLATE# PLATE# TRLR zRLR 1 1 5 33 12 3 0 VIN#' vIN# FROM TO VEH.YEAR 2019 MAKE N/$$ MODEL SENTRA STYLE $D VEHICLE TOWED TO BLIN TOWED By GES VEHICLE 9 9 34 13 DAMAGE YES ✓ YES NO✓ REGISTERED OWNER INFO ISATOU SANNEH 1711124TH PL SE EVERETT WA 98203 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35 3 4 14 LIABILITY INSURANCE❑ NSURANCE CO NONE IN EFFECT &POLICY# CDQ, VEHICLE CHARGE 36 YES❑NO❑ CITATION# 15❑ srnNowc s 7 e UNIT 02 MOTCR PEDAL- ❑ PEDESTRIAN PROPERTY DAM THR OLD MET PHONE VEHICLE CYCLE nWNRR YES�/ NO 16� LAST NAME BARC/NAS FIRST NAME EVANDER MIDDLE G INITIAL 17 F1 STREET ❑ 13790 56TH AV S I-301 CITY TUKWILA ST, WA ZIP 98168 37 NEW ADDRESS I I I I I I [I 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSP©RTED ❑ 38 INTERLOCKYEs NO✓ INTERLOCK YES ND✓ vEs ND✓ 19 DRIVERS ' STATE WA SEX M I D.O.B. 10 21 1992 � 39 LICENSE# MMDDYY — HELMET INJURY NATURE OF INJURIES 40 20❑ ON DUTY� STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑ 21 LICENSE I PLATE# CKR6192 rare WA vIN# JTHCM1D21H5017213 41 22❑ [TILER TAILER PLATE# STATE PLATE# STATE 42 43 VfN 23 RLR UIN#. 'IN# VEH.YEAR 2017 MAKE LEXS MODEL IS 250 STYLE $D VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES NO✓ VES NO✓ REGISTERED OWNER INFO STEPHANIE ZAMUDIO VALADEZ 1379056TH AVS1.301 TUKWILA WA 98168 VEHICLE NO.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE[Z INSURANCE CO STATE FARM 569 9726 D31478 IN EFFECT &POLICY# I STOP 1-IL YES NIL]IL] CITATION# CHARGE to BOTTOM 25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 HANSEN HSU 12651 WA0171300 PAGE 01 OF PART A 3000-348-189(R 11/18) STATE OF POLICETRAFFICN CORRECTION REPORT NO. EG69584 COLLISION REPORT III III III III III 111 1591972 CASE# 26-474 ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY) '.NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE SEXi D.O.B. — MMDDYYYY PASSENGERQ WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ; HELMET NJURY NATURE OF INJURIES POS. ' USE CLASS 1 ----� :NAME (LAST FIRST MIDDLE INITIAL) ADDRESS&PHONE# SEX D.O.B. — MMDDYYYY PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURECFINJURIES POS. USE CIASS ----� :NAME (LOST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE# SEX MMDDYY D.O.B. YY PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES POS. I USE CLASS NARRATIVE Unit 2 driver reported vehicle collision three hours prior from time of dispatch at 300 block of Sunset Blvd N. Unit 2 driver reported that Unit 1 rear ended Unit 2 causing reportable non disabling front end damage to Unit 1 and reportable non disabling rear end damage to Unit 2. No injuries reported. Unit 2 driver reported that Unit 1 driver provided WA State DOC identification and that he also obtained the license plate to Unit 1, before Unit 1 driver vacated scene. Unit 1 driver proximate cause of collision. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. HANSEN HSU 01-16-26 08:08 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE CASEYPROCTER 12123 1/1712026 1:01:00 AM BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 1 6:45 PM TIME POLICE ARRIVED i 6:47 PM (PART B 3 Da-3m5—attar(t 1Mff) PAGE 2�OF F3 REPORT NO. EG69584 CASE# 26-474 DATE AND TIME 01/16/26 15:30 OF COLLISION s � 0 E nn r „ka 4 t k y " \S 7, -' s k� iist�a�t+�� llivi s "xke, k� 1 k Y' � 1 k } r z PAGE 3 OF 3